• You are the nurse on a medical unit taking care of a 50-year-old man, A.A.

, who was
admitted 18 hours ago with peptic ulcer disease secondary to suspected chronic alcoholism.
You enter A.A.’s room and find him having a generalized convulsive (tonic-clonic) seizure.

1. What is your immediate concern for A.A.? A.A’s respiratory function must be
assessed continually while he is convulsing. He will need to be assessed for
positioning that may endanger his airway or place him in at risk for aspiration. He will
need high flow O2 via non rebreather if his SAO2 drop below 95%. He needs a pillow
under his head and the bed needs to be padded to protect him from hurting himself.
His glucose needs to be assessed and any hypoglycemia needs to be treated
effectively. He needs his thiamine levels checked to assess for possible Wernicke
encephalopathy that could be causing the seizure.

2. List 5 things you would do in order of priority.

1. Call for help. Do not leave patient unattended. 2. Support respirations and protect
airway. 3. Position patient to avoid aspiration. 4. Administer 100% O 2 by mask or
bag-mask as needed. 5. Protect A.A., especially his head, by making certain the
environment is safe. 6. Obtain blood for pertinent labs when it is safe to do so.

3. Given A.A.’s history, state 3 possible causes for his tonic-clonic seizure.

1. Wernicke encephalopathy from thiamine deficiency. 2. Withdrawal from alcohol. 3.

possible meningitis. 4. Hypoglycemia can cause seizures. 5. Any number of possible
disorders that cause siezures if the patient has a history of seizure activity.

CASE STUDY PROGRESS

The rapid response team is called, and the provider gives the orders shown in the chart.
Chart View

Medication Administration Record

Thiamine (vitamin B1) 100 mg IM now

50% glucose, 1 50-mL IV bolus now
Lorazepam (Ativan) 4 mg IV now over 2 to 5 minutes

4. Indicate the expected outcome for A.A. associated with each medication.

Thiamine is given if alcohol withdrawal is suspected or a possibility to protect against

Wernicke's encephalopathy.Glucose is given to correct hypoglycemia secondary to
 prolonged muscle activity. Lorazepam decreases abnormal electrical impulse
production associated with status epilepticus and is generally agreed to be a first-line
drug of choice for attempting to control seizure activity.

5. In what order would you give A.A.’s medications? Give your reason.

___3__ Thiamine (Vitamin B1)

___2__ Glucose
___1__ Lorazepam (Ativan)

6. List your primary concern when giving lorazepam intravenously. Respiratory

depression.

7. (S) The lorazepam is supplied in a single-use vial. How many milliliters will A.A. receive?
Shade in the dose on the syringe.

Correct answer: 1 mL

8. What assessments do you need to make during his ongoing seizure activity? The ABCs
(A irway, B reathing, C irculation) should be evaluated as necessary, including
oxygenation and airway assessment. Also glucose levels and in this case ICP.
CASE STUDY PROGRESS

A.A.’s seizure activity does not subside. The provider orders an additional 4 mg of IV
lorazepam without effect. Twenty minutes has now elapsed since you initially found A.A.
having seizure activity.

9. What is the significance of this time lapse? This patient shows signs of status
epilepticus that requires immediate intervention.

10. Define status epilepticus. two or more sequential seizures without full recovery of
consciousness between seizures, or more than 30 minutes of continuous seizure
activity. Any person who exhibits persistent seizure activity or who does not regain
consciousness for five minutes or more after a witnessed seizure should be
considered to have status epilepticus.

11. The provider decides to administer propofol (Diprivan) and intubate A.A. to support his
airway. What is propofol? Why is it being given to A.A.? Propofol is a general anesthetic
and is given to A.A to sedate him so his airway can be secured.

12. The provider also orders a phenytoin 15 mg/kg IV loading dose at a rate of 50 mg/min.
What is the reason for giving A.A. phenytoin? Phenytoin limits seizure propagation by
altering ion transport. It is being giving to A.A to treat/prevent tonic-clonic (grand mal)
seizures and complex partial seizures.

13. (S) A.A. weighs 143 pounds. How much phenytoin will you administer? 975mg. Rate
not to exceed 25–50 mg/min.

14. (S) As you prepare to administer the phenytoin, you see that A.A. has D5W infusing at
75 mL/hr. Why does this concern you, and what are your options? Dilantin to dextrose and
dextrose-containing solutions should be avoided due to lack of solubility and
resultant precipitation. Ask the doctor if the D5W infusion can be changed to NS.

15. You accompany A.A. as the rapid response team transfers him to the ICU. During the
transport, his seizure activity ceases. Using SBAR, what information will you provide to the
ICU nurse? Situation: Identify the patient and state that the patient had a seizure.
Background: Summarize why the patient is in the hospital. Then, describe the seizure
in detail and the patient’s postictal condition, including vital signs.
Assessment: State the type of seizure you think the patient had. Note whether the
patient has a history of seizures.
Recommendations: Report that you have implemented seizure precautions and
recommend appropriate tests and medications.

16. What are the main complications of status epilepticus that the nurse will monitor for?
The most important systemic signs are fever, acidosis, cardiac ar-rhythmia,
hypoglycemia, and respiratory distress

17. Describe the assessment A.A. needs over the next few hours. Q 15 minutes VS
including Temp. Constant cardiac monitoring. Regular ACCU checks. ABG’s.
Continual focused assessment of respiratory function.

18. Identify nursing interventions that are appropriate for A.A. since the seizure activity has
subsided. Patient safety is the main concern. Protect the airway. Keep him lying on his
side. Lower the bed to lowest setting a raise all side rails. Frequently reorient the
patient during delirious state and stay at the bedside until A.A. fully recovers.
CASE STUDY OUTCOME

A.A.’s seizure is successfully treated with lorazepam and phenytoin, and he has no further
seizure activity. After his acute care needs are resolved, A.A. decides to enter a
detoxification program on discharge. He successfully completes the program and remains
free of drug and alcohol use.